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Mindfulness & EMDR for �Sex Trafficking Survivors

Hope Aspenleiter

Fall A

PSY565

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Background

Human trafficking encompasses forced labor and sex trafficking. This proposal focuses on supporting victims of commercial sex trafficking, defined as force, fraud, or coercion by traffickers to compel victims to preform commercial sex acts.

Source: Department of Homeland Security

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28,000,000

Trafficked People Worldwide

Source: Polaris Project

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What is Commercial Sex Trafficking

Traffickers use coercion, force or fraud to compel victims to engage in commercial sex acts.

Not all commercial sex is considered human trafficking.
Not all victims realize they are being exploited.

Victims often know their traffickers.

Often in a romantic relationship with them

Source: Department of Homeland Security; Polaris Project; Clawson et al., (2007).

Traffickers often gain an advantage over their victims bonding with and grooming them. This progresses to more forceful, coercive or fraudulent acts. According to the department of homeland security, traffickers often look for victims who may not speak the foreign language, have many relationships, are displaced due to natural disasters or political instability, are struggling with economic hardship or are psychologically vulnerable. In the case that one has a social bonds, victims will likely coerced into ending the relationships and threatened or harmed if they behave in ways the trafficker deems unacceptable. Because of the deep manipulative factor and secrecy at play in these relationship dynamics, victims my not recognize that they are being abused or attempt to conceal their involvement in fear of repercussions.

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Impact on Victims

Source: Litam & Neal (2022); Lederer & Wetzel (2014); Countryman-Roswurm & Shaffer (2015)

Mental
Anxiety
Guilt & Shame
Hyperarousal
Dissociation
Depression
Suicidal Ideation
Flashbacks

Physical
Sleep Disturbances
Sexually Transmitted Diseases
Infertility
Injuries from Abuse

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Comorbid Conditions

Substance Abuse
Eating Disorders
Insomnia
Post Traumatic Stress Disorder
Anxiety
Depression
Gynecological Conditions

Source: Lederer & Wetzel (2014)

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Neurological Effects of Trauma

Decreased Medial Prefrontal Functioning

Amygdala Overrides Prefrontal Cortex

Increased Limbic Activation

PTSD

Source: Bremner J. D. (2006); Boyd et al., (2018)

Altered Perception of World

Altered Sense of Self

Heightened Stress Response to Triggers

It has been found that PTSD alters one's neurobiology which is what some scientists believe plays a role in the disorder's expression. Building off of this idea, my intervention is designed to address emotional reactivity by promoting emotional regulation. The parts of the brain most responsible for emotional regulation are the prefrontal cortex and the amygdala, which is part of the limbic system. The amygdala sends signals to the prefrontal cortex, which uses information in concurrence with other brain signals to determine when a threat is present. When the prefrontal cortex is disrupted, it can no longer deescalate an activated amygdala resulting in the belief that we are in danger.

An intervention designed to promote healthy emotional regulation would then require special attention paid to the altered functioning of these brain networks to restore optimal communication between default mode network (DMN), central executive network (CEN), and salience network (SN) which are all thought to be disrupted in PTSD.

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Overview

This intervention aims to alleviate emotional reactivity and social withdrawal in sex trafficking survivors. It will focus on teaching healthy emotional regulation strategies and learning to identify feelings.

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Target Population

The intervention is designed specifically for adult women who suffer from Post Traumatic Stress Disorder after being subjected to sex trafficking.

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Therapeutic Methods

Restore connectivity between brain networks disrupted by traumatic events.

Supports mind-body connection, allowing survivors to regain awareness of their emotional responses.

Aids in developing adaptive emotional regulation strategies and limiting dissociative symptoms.

Mindfulness Practices

Eye Movement Desensitization

& Reprocessing

Allows for the processing of traumatic memories that impact our mental and physical health.

Bilateral stimulation & saccadic eye movements to relax distress in the brain and encourage healing.

Supports survivors reprocessing traumatic events into standard biographical memories.

Source: Hepburn (2017); Salami et al., (2018); Boyd et al., (2018);

The methods that I propose to be used in this intervention are a combination of mindfulness practices and eye movement desensitization and reprocessing. Mindfulness practices include meditation, journaling and breathing exercises help improve connectivity between brain regions disrupted by PTSD. This helps decrease dissociative or hyperarousal symptoms by fostering present moment awareness and rebuilding mind-body awareness. It is especially important that mindfulness practices are used prior to EMDR to ensure that the patient has ample time to boost connectivity and functioning of compromised brain networks to limit dissociative symptoms. Only once a patient feels they have more awareness and control over their physiological responses should EMDR be introduced.

EMDR has most commonly been used to support processing a single traumatic event and not in cases of complex trauma like many sex trafficking survivors. That said, it has shown to be an effective method of surfacing a traumatic memory without having to relive it. When victims are in survival mode, their ability to connect their thoughts to their feelings is disrupted. Using EMDR, survivors are provided a safe place to allow these unprocessed memories to resurface. Using bilateral stimulation, trained professionals can assist in neutralizing a triggering memory so it can later be addressed without the heightened emotional response that it caused before.

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Measured Outcomes

Skill	Measurment Following Questions on the PCL-5	Expected Outcome
Emotional Reactivity	Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)? Feeling very upset when something reminded you of the stressful experience? Having strong negative feelings such as fear, horror,�anger, guilt, or shame? Irritable behavior, angry outbursts, or acting�aggressively? Being “superalert” or watchful or on guard?	Decreases
Social Withdrawal	Loss of interest in activities that you used to enjoy? Feeling distant or cut off from other people? Avoiding external reminders of the stressful experience Avoiding memories, thoughts, or feelings related to the stressful experience?	Decreases

This intervention is targeted at addressing emotional reactivity and social withdrawal within adult women survivors of sex trafficking. Emotional reactivity will be measured using the PCL-5 scale, where survivors answer questions as it relates to their trafficking experience. The questions that measure emotoional reactivity include: (read slide). Social withdrawal will be evaluated using the PCL-5 scale, which measures residual trauma as it relates to survivors experience. The questions that specifically address social ithdrawal are: (read from slide).

It is expected that the intervention will aid in the development of adaptive forms of emotional regulation. In turn, survivors will become more aware stressful or triggering situations and can utilize healthy strategies to deescalate their reaction to the stressor. This benefit will be seen with social withdrawal too, as the building of trust between a therapist and survivor and regulation of emotions should encourage more control of social dynamics. Addressing emotional reactivity will likely show its effects in lessening social withdrawal too, as the gained awareness over internal states and control over external reactions would lead one to feel more confident in social situations where one is not in control of their environment.

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Required Materials

PCL-5 assessment (PTSD Checklist)
Professional trained in Mindfulness & EMDR
Pre-recorded guided Sitting / Walking Meditations
Pre-recorded guided Body Scan
Pre-recorded guided gentle Yoga Session
Mindfulness Practice Log
Cellphone, Tablet or Computer
Internet Access
Journal
Reliable transportation

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Intervention Procedure

Step 1: Mindfulness Practice

The survivor meets with therapist to mindfulness coach learn informal mindfulness techniques.

The therapist shares access to pre-recorded guided mindfulness sessions

Sitting or walking meditations, body scanning, gentle yoga (all less than 60 minutes).
Complete at least one guided session daily.

The therapist gives survivors practice log to track when they complete a mindfulness session.

Includes date, time, and notes section for anything that they experienced and would like to address.

This intervention has three phases, designed to be done in addition to each other. The first phase focuses on being presently aware of our internal experience. The survivor begins by meeting with the therapist who will be with them throughout the process to aid in establishing trust with the patient. It is important to ensure the professional is open, nonjudgemental, and has a proper understanding of trauma responses. The ability of the survivor to choose which mindfulness practice they partake in is vital due to the lack of choice that they experienced during their trauma.

Accessing the pre-recorded mindfulness sessions requires an internet device and internet access and take no more than one hour. Survivors are given a practice log to track the date and time they completed the mindfulness session, along with space for any notable emotions, memories, thoughts or sensations that arose during their session.

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Intervention Procedure

Step 2: Journaling

Survivors meet with therapist again to go over mindfulness practice log, address any notes.
Journaling is added to daily routine.
Encouraged to identify moments of intense emotions.

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Intervention Procedure

Step 3: EMDR

Meet with the therapist again to go over anything that arose during the mindfulness & journaling exercises that the survivor would like to discuss.
Sessions take place with the same licensed therapist from mindfulness sessions.
Meet 2x weekly for 60 to 90 minute sessions.
In-person at the therapist's office or another safe, private space.

The third step of the intervention is the integration of EMDR therapy. For some survivors, it will take longer to reach this point as it is imperative that EMDR is not preformed on individuals experiencing dissociative symptoms. The time in which a therapist and their client move onto EMDR is to be determined on an individual basis and should not be forced on any survivor who does not feel comfortable.

When ready, the survivor will meet with the therapist to go over any concerns from the journaling / mindfulness excercises. If comfortable, the first EMDR session is preformed that same day. In these sessions, survivors will be guided back to a traumatic event where they are instructed to preform specific eye movements that aid in the reprocessing of these memories to limit the strength of their emotional response within one's body. This is most frequently preformed in a therapist office but can be done in a private, safe place.

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Expected Timeline

Mindfulness

EMDR

TherapeuticJournaling

1 Week

2 + Weeks

Source: Mirgain & Singles (2016)

The first week of the intervention will be spent practicing mindfulness techniques including meditations, body scanning, breathing practices, yoga, and informal mindfulness. This first week should provide a basis for which the next steps builds, and help survivors become more in tune with their bodies signals and less likely to experience dissociative symptoms.

In rebuilding the damaged mind-body relationship, some discomfort is bound to arise. This is why the next stage of the intervention is adding journaling for one week. In doing so, survivors have an outlet to connect with themselves without having to go back and relive the traumatic experiences that brought on this state. According to the Office of Veteran Affairs, therapeutic journaling, or the regular tracking of things that cause us to experience fear, anger, grief, anxiety, joy, and other strong emotions, can allow us to gain a deeper understanding of ourselves and the things that trigger us. These perceptions are often related to the trauma one has experienced and, with the support of a trained professional, can be highly beneficial in identifying triggers that can be addressed in the next phase of the intervention.

After one weeks of practicing mindfulness and one week of journaling, if the survivor is experiencing less dissociative symptoms and is comfortable moving to the next step then EMDR therapy is to be introduced. These will be completed in addition to daily mindfulness practices and therapeutic journaling and will take place twice weekly for 60 to 90 minutes. While some people may notice relief after two weeks, others may need more time to support the reprocessing of their traumatizing memories or have more experiences they need to work through. The length and frequency are custom to the needs of each individual as they are the experts on their own experience and know their needs better than anyone else. If therapy continues past the two week mark, care is to be managed by both the professional and the survivor to ensure all residual concerns are addressed.

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Evaluation Criteria

Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?
Feeling very upset when something reminded you of the stressful experience?
Having strong negative feelings such as fear, horror, anger, guilt, or shame?
Irritable behavior, angry outbursts, or acting aggressively?
Being “superalert” or watchful or on guard?

Emotional Reactivity

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Evaluation Criteria

Loss of interest in activities that you used to enjoy?
Feeling distant or cut off from other people?
Avoiding external reminders of the stressful experience
Avoiding memories, thoughts, or feelings related to the stressful experience?

Social Withdrawal

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Anticipated Effects

Decreased

Emotional Reactivity

Social Withdrawal

Seen by a statistically significant decrease in PCL-5 scores

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Proposed Mechanism of Action

Boyd et al., (2018)

Increased Prefrontal Cortex Activation

Limbic System Modulation

Mindfulness Practices

Feeling Identification

Decreased

Arousal
Intrusive

Thoughts

Reduced Stress Response

Adaptive Emotional Regulation

Clinically, this will look like the use of adaptive regulation strategies like cognitive reappraisal. The survivor will present less hyperarousal symptoms as measured by the PCL-5 while becoming more socially trusting and confident in their identities.

Neurologically, as found by Boyd et al., the mindfulness component of the intervention will increase prefrontal cortex activity and regulate the limbic system including the amygdala. In theory, this should reduce intrusive thoughts and arousal, which is key to allowing for the identification of feelings and healthy emotional regulation to occur.

Further, fostering connection between these brain regions is suspected to decrease symptoms of depression and anxiety. The ability of mindfulness practices to address emotional under and overmodulation can result in reduced hyperarousal and dissociative symptoms.

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Limitations

Lack of internet accessible device or connection.

Solution: �Therapists provide clients without an internet device with one that only contains the guided sessions. Sessions can also be downloaded onto a flash drive that patient can download onto their computer for continued use.

Inability to use EMDR on patients with dissociative symptoms

Solution: �Because the intervention is completed at a pace designed by the therapist and the patient, EMDR can be introduced when the patient is ready. Alternatively, other creative therapies may assist the process of lessening dissociative symptoms.

While this intervention is designed to include as many survivors as possible, there are some limitations. One of them being the need for reliable internet access, which may be unavailable to individuals recently exiting sex trafficking with little financial or social support. A way to address this may be providing a device with guided sessions predownloaded, or giving them a flash drive that can be uploaded to their device regardless of internet access.

Another limitation that may impact this intervention is the inability to use EMDR therapy on patients experiencing dissociative symptoms. While this one is harder to solve, one means of limiting complications is to practice mindfulness first and progress on a timeline set by the therapist and patient. If a patient presents dissociative symptoms of any form, it is important to stay in phase 1 & 2 until they have subsided.

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Conclusion

In all, the treatment of sex trafficking survivors must be:

Individualized.
Trauma informed.
Socially focused.
Led by survivors.

Only survivors know the extent of their experiences and should be considered experts of their own health. Optimal interventions address the need for trusting relationships while providing survivors with resources to connect with themselves and regain control over their lives.

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REFERENCES

Boyd, J. E., Lanius, R. A., & McKinnon, M. C. (2018). Mindfulness-based treatments for posttraumatic stress disorder: A review of the treatment literature and neurobiological evidence. Journal of Psychiatry and Neuroscience, 43(1), 7-25.

Bremner, J. D. (2006). Traumatic stress: Effects on the brain. Dialogues in Clinical Neuroscience, 8(4), 445–461. https://doi.org/10.31887/DCNS.2006.8.4/jbremner

Clawson, H. J., Salomon, A., & Grace, L. G. (2007). Treating the hidden wounds: Trauma treatment and mental health recovery for victims of human trafficking. U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation.

Department of Homeland Security. (n.d.). What is human trafficking? U.S. Department of Homeland Security. https://www.dhs.gov/blue-campaign/what-human-trafficking

Hepburn, S. (2017, July). EMDR therapy used to neutralize human trafficking trauma. National Association of State Mental Health Program Directors. https://www.nasmhpd.org/sites/default/files/StephanieHepburnNASMHPDSexualAssaultinHT.pdf

Lederer, L. J., & Wetzel, C. A. (2014). The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities. Annals Health Law, 23, 61.

Litam, S. A., & Neal, S. (2022). Trauma-informed interventions for counselling sex trafficking survivors. International Journal of Advanced Counseling, 44, 243–262. https://doi.org/10.1007/s10447-022-09465-1

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REFERENCES

McCaw, A. (2019). Use of mindfulness to treat mental health symptoms of individuals subjected to human sex trafficking and prostitution (Dissertation No. 370). https://digitalcommons.nl.edu/diss/370

Mirgain, S. A., & Singles, J. (2016, updated 2023). Therapeutic journaling. VA Office of Patient Centered Care and Cultural Transformation. University of Wisconsin Integrative Health Program, Pacific Institute for Research and Evaluation. https://www.va.gov/WHOLEHEALTHLIBRARY/tools/creating-gratitude-practice.asp

Polaris Project. (n.d.). Homepage. https://polarisproject.org

Salami, T., Gordon, M., Coverdale, J., & Nguyen, P. T. (2018). What therapies are favored in the treatment of the psychological sequelae of trauma in human trafficking victims? Journal of Psychiatric Practice, 24(2), 87–96. https://doi.org/10.1097/PRA.0000000000000288

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Thanks!

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